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Long B, Gottlieb M. Managing Peritonsillar Abscess. Ann Emerg Med 2023; 82:101-107. [PMID: 36669912 DOI: 10.1016/j.annemergmed.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Use of Needle Guide for Dynamic Real-Time Ultrasound-Directed Aspiration of Peritonsillar Abscess in the Emergency Department: A Case Series. J Emerg Med 2023; 64:345-352. [PMID: 36925440 DOI: 10.1016/j.jemermed.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Needle aspiration is a common treatment of peritonsillar abscess (PTA). Point-of-care ultrasound (POCUS) can be used to guide this procedure. We describe our experience using a commercially available needle guide attached to an endocavitary ultrasound probe for dynamic real-time POCUS-guided PTA needle aspiration. DISCUSSION A convenience sample of patients were treated using the needle guide. The primary author (Peter Kumasaka) performed or supervised emergency medicine residents and physician assistants (PAs) for each case in which the needle guide was used. The electronic medical records were abstracted for procedure success, various length of stay (LOS) data, and to determine use of computed tomography imaging and otorhinolaryngologist (ENT) consultation. Dynamic POCUS-guided needle aspiration using the needle guide (DNG) was performed on 8 patients. There were no unexpected return visits to the emergency department (ED) or to the ENT clinic for any of the patients. The median time to perform DNG was 9 min (range 8-17 min). Median LOS was 182 min (range 78-287 min). Median time from POCUS order to patient discharge was 82.5 min (range 66-237 min). Median time from starting procedure to discharge was 43 min (range 18-148 min). CONCLUSIONS The needle guide is a useful adjunct to assist in PTA drainage. It provided rapid, safe, and efficient care. Additional research is needed to see how this technique compares with more traditional methods of PTA drainage.
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Muacevic A, Adler JR, Rometti M, Wei G, Morrison D, Geria R, Mccoy JV. Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess. Cureus 2022; 14:e32207. [PMID: 36620852 PMCID: PMC9812542 DOI: 10.7759/cureus.32207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Patients presenting to the Emergency Department (ED) with a suspected peritonsillar abscess (PTA) often pose a diagnostic dilemma, as clinical impression is often unreliable and traditional diagnostic methods have multiple downsides. Bedside ultrasonography has been cited as a modality to improve the diagnosis and management of PTA. We aimed to determine the impact bedside ultrasound (US) could have in suspected PTA on ED length of stay (LOS) and hospital admission rates. Methods We performed a retrospective chart review on patients who presented to the ED with suspected ''peritonsillar abscess''. Results From a sample of 58 charts, seven had documented bedside US performed. The average ED length of stay for these seven cases was 160 minutes (range: 52 to 270 minutes). The ED length of stay for all other cases utilizing other diagnostic methods during the same time period was 293 minutes (range: 34 to 780 minutes). None of the patients who were diagnosed with US were admitted to the hospital, whereas 36.4% of patients where US was not used were admitted. Conclusion The use of bedside US in seven cases of suspected PTA had reduced LOS in the ED and none required hospital admission.
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Brown JR, Knight R. SONO case series: peritonsillar abscess. Emerg Med J 2021; 38:730-732. [PMID: 34413134 DOI: 10.1136/emermed-2019-209417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Joseph Roland Brown
- Emergency Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Roneesha Knight
- Emergency Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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Menegas S, Moayedi S, Torres M. Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. J Emerg Med 2020; 60:310-320. [PMID: 33298356 DOI: 10.1016/j.jemermed.2020.10.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/02/2020] [Accepted: 10/19/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses. OBJECTIVE This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department. DISCUSSION Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative. CONCLUSIONS This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.
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Affiliation(s)
- Samantha Menegas
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Siamak Moayedi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mercedes Torres
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med 2020; 59:693-698. [PMID: 32826122 DOI: 10.1016/j.jemermed.2020.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10-24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management. OBJECTIVES Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al. METHODS Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007-December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data. RESULTS Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p < 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04-0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p < 0.0001; OR 25 [95% CI 10-59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p < 0.0001; OR 24 [95% CI 3-193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p < 0.0001; OR 0.07 [95% CI 0.03-0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25-1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05-0.61]). CONCLUSION POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS.
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Affiliation(s)
- Ryan C Gibbons
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Thomas G Costantino
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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Abstract
The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care, particularly in the world of pediatrics. Children are prime candidates for ultrasound because they are more at risk to the harmful effects of ionizing radiation than adults. This is the second part of a two-part article reviewing 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(4):e196-e200.].
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Hagiwara Y, Saito Y, Ogura H, Yaguchi Y, Shimizu T, Hasegawa Y. Ultrasound-Guided Needle Aspiration of Peritonsillar Abscesses: Utility of Transoral Pharyngeal Ultrasonography. Diagnostics (Basel) 2019; 9:diagnostics9040141. [PMID: 31590411 PMCID: PMC6963430 DOI: 10.3390/diagnostics9040141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 01/29/2023] Open
Abstract
A peritonsillar abscess is a common deep infection that is usually related to acute tonsillitis. Needle aspiration is often performed for diagnosis and treatment, but several complications, including puncture of the carotid artery, may occur, even when performed by properly trained physicians. The utility of transoral pharyngeal ultrasonography (TOPU) equipped with a biopsy adaptor for safe and full aspiration is presented. A 19-year-old man was admitted to our hospital because of a peritonsillar abscess. TOPU showed the abscess and a branch of the carotid artery, and an otolaryngologist performed puncture through the biopsy adaptor with the aid of the ultrasound image. Needle aspiration was accomplished by avoiding arterial puncture and monitoring the shrinkage of the abscess. TOPU-guided needle aspiration is useful in the safe drainage of peritonsillar abscesses.
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Affiliation(s)
- Yuta Hagiwara
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (H.O.); (T.S.); (Y.H.)
- Correspondence:
| | - Yoshimitsu Saito
- Department of Otorhinolaryngology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (Y.S.); (Y.Y.)
| | - Hana Ogura
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (H.O.); (T.S.); (Y.H.)
| | - Yuichiro Yaguchi
- Department of Otorhinolaryngology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (Y.S.); (Y.Y.)
| | - Takahiro Shimizu
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (H.O.); (T.S.); (Y.H.)
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan; (H.O.); (T.S.); (Y.H.)
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Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol 2019; 123:22-25. [PMID: 31054537 DOI: 10.1016/j.ijporl.2019.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/04/2019] [Accepted: 04/18/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objective of this study is to examine the impact that an institution-wide policy to reduce radiation exposure in pediatric patients had on the use of computed tomography (CT) imaging in children presenting with suspected peritonsillar abscess (PTA)1. METHODS A single institution retrospective review was conducted for all pediatric patients under the age of 18 who presented to the emergency department with suspected PTA over a ten-year period. Patients were divided into two groups; those that presented during the years prior to policy implementation and those that presented during the years following. Main outcome measures were the frequency of patients who underwent CT scanning as a part of their workup, the specialty of the ordering physician, and the treatment for suspected PTA. RESULTS A total of 317 patients with suspected PTA were seen prior to policy implementation, with an additional 275 patients seen in the years after. The frequency of CT use was 41% (131/317) in pre-policy patients, and 28% (77/275) in post-policy patients (p = 0.004). The most common specialty of ordering physician was Pediatrics in the pre-policy patients (45%), and Otolaryngology in the post-policy patients (41%) (p = 0.0003). Of the 131 patient who underwent CT scanning before policy implementation, 36 patients (27%) required incision and drainage (I&D) of their PTA in the OR. This is in comparison to 42/77 patients (55%) in the post-policy group who underwent I&D in the OR (p < 0.0001). CONCLUSION An institution-wide policy to decrease unnecessary imaging studies in pediatric patients resulted in a significant reduction in the use of CT imaging in the work-up for suspected PTA. Additionally, there was increase in the frequency of patients who underwent surgical intervention for their PTA after CT imaging, suggesting a more scrutinized approach to CT usage since policy implementation.
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Affiliation(s)
- Kasey W Rawlins
- The Ohio State University Wexner Medical Center, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA
| | - David Z Allen
- The Ohio State University Wexner Medical Center, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA
| | - Amanda J Onwuka
- The Research Institute at Nationwide Children's Hospital, Center for Surgical Outcomes Research, Columbus, OH, USA
| | - Charles A Elmaraghy
- The Ohio State University Wexner Medical Center, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA; Nationwide Children's Hospital, Department of Pediatric Otolaryngology-Head and Neck Surgery, Columbus, OH, USA.
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A Novel Technique for Intraoral Ultrasound-Guided Aspiration of Peritonsillar Abscess. Diagnostics (Basel) 2018; 8:diagnostics8030050. [PMID: 30072648 PMCID: PMC6174334 DOI: 10.3390/diagnostics8030050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023] Open
Abstract
Peritonsillar abscess (PTA) is a common complication to acute tonsillitis. The treatment is drainage of the abscess, but many needle aspirations are unsuccessful due to a low diagnostic accuracy based on oral examination only. In this article, we describe how intraoral ultrasound can be added to improve the diagnostic work-up of PTA and present a novel technique for ultrasound-guided aspiration of PTA, using a small pencil-shaped transducer. We present our first clinical experiences with this technique and describe how it could be integrated in a clinical setting to guide safe and successful needle aspirations of PTA.
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11
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Suri P, Aurora TK. Care of Infectious Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:647-671. [PMID: 28711129 DOI: 10.1016/j.emc.2017.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Infectious conditions such as skin and soft tissue infections (SSTIs), Urogenital infections and peritonsillar abscesses frequently require care beyond emergency stabilization and are well-suited for short term care in an observation unit. SSTIs are a growing problem, partly due to emergence of strains of methicillin-resistant S. aureus (MRSA). Antibiotic choice is guided by the presence of purulence and site of infection. Purulent cellulitis is much more likely to be associated with MRSA. Radiographic imaging should be considered to aid in management in patients who are immunosuppressed, have persistent symptoms despite antibiotic therapy, recurrent infections, sepsis or diabetes.
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Affiliation(s)
- Pawan Suri
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 1200 E Marshall Street, Richmond, VA 23298, USA.
| | - Taruna K Aurora
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 1200 E Marshall Street, Richmond, VA 23298, USA
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12
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Prokofieva A, Modayil V, Chiricolo G, Ash A, Raio C. Ultrasound-guided drainage of peritonsillar abscess: shoot with your hockey-stick. Intern Emerg Med 2016; 11:883-4. [PMID: 26543001 DOI: 10.1007/s11739-015-1343-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 10/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Ann Prokofieva
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Veena Modayil
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Gerardo Chiricolo
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY, USA
| | - Adam Ash
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA.
| | - Christopher Raio
- Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
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Diagnosis of a Peritonsillar Abscess by Transcutaneous Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care 2016; 32:489-92. [PMID: 27380609 DOI: 10.1097/pec.0000000000000843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of a pediatric patient with an initial diagnosis of peritonsillar cellulitis made by otolaryngology. The findings from a subsequent transcutaneous point-of-care ultrasound by a pediatric emergency physician directly affected the decision to perform needle aspiration. Sonographic characteristics of a peritonsillar abscess may be helpful in the prompt diagnosis of peritonsillar abscess.
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14
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Bacon E, Tabbut M. When a peritonsillar abscess is not a peritonsillar abscess: using bedside emergency ultrasound to change the diagnosis. Am J Emerg Med 2016; 34:1186.e5-7. [DOI: 10.1016/j.ajem.2015.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/07/2015] [Indexed: 12/01/2022] Open
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Healthy 51-year-old male with peritonsillar swelling. Squamous cell carcinoma. Ann Emerg Med 2015; 61:520, 527. [PMID: 23622021 DOI: 10.1016/j.annemergmed.2012.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 09/28/2012] [Accepted: 10/01/2012] [Indexed: 11/21/2022]
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Henneberry RJ, Hanson A, Healey A, Hebert G, Ip U, Mensour M, Mikhail P, Miller S, Socransky S, Woo M. Use of point of care sonography by emergency physicians. CAN J EMERG MED 2015; 14:106-12. [DOI: 10.2310/8000.caepps] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Secko M, Sivitz A. Think ultrasound first for peritonsillar swelling. Am J Emerg Med 2015; 33:569-72. [DOI: 10.1016/j.ajem.2015.01.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/16/2015] [Accepted: 01/17/2015] [Indexed: 11/30/2022] Open
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Pahlevaninezhad H, Lee AMD, Rosin M, Sun I, Zhang L, Hakimi M, MacAulay C, Lane PM. Optical coherence tomography and autofluorescence imaging of human tonsil. PLoS One 2014; 9:e115889. [PMID: 25542010 PMCID: PMC4277424 DOI: 10.1371/journal.pone.0115889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/27/2014] [Indexed: 01/17/2023] Open
Abstract
For the first time, we present co-registered autofluorescence imaging and optical coherence tomography (AF/OCT) of excised human palatine tonsils to evaluate the capabilities of OCT to visualize tonsil tissue components. Despite limited penetration depth, OCT can provide detailed structural information about tonsil tissue with much higher resolution than that of computed tomography, magnetic resonance imaging, and Ultrasound. Different tonsil tissue components such as epithelium, dense connective tissue, lymphoid nodules, and crypts can be visualized by OCT. The co-registered AF imaging can provide matching biochemical information. AF/OCT scans may provide a non-invasive tool for detecting tonsillar cancers and for studying the natural history of their development.
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Affiliation(s)
- Hamid Pahlevaninezhad
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Anthony M. D. Lee
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Miriam Rosin
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Ivan Sun
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Lewei Zhang
- Department of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mehrnoush Hakimi
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Calum MacAulay
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
| | - Pierre M. Lane
- Department of Integrative Oncology, British Columbia Cancer Research Center, Vancouver, British Columbia, Canada
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19
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Falcon-Chevere JL, Giraldez L, Rivera-Rivera JO, Suero-Salvador T. Critical ENT skills and procedures in the emergency department. Emerg Med Clin North Am 2013. [PMID: 23200328 DOI: 10.1016/j.emc.2012.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Injuries and illness to the ears, nose, and throat are frequently seen in the emergency department. The emergency medicine physician must be proficient in recognizing these injuries and their associated complications and be able to provide appropriate management. This article discusses the most common otorrhinolaringologic procedures in which emergency physicians must be proficient for rapid intervention to preserve function and avoid complications. A description of each procedure is discussed, as well as the indications, contraindications, equipment, technique and potential complications.
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Affiliation(s)
- Jorge L Falcon-Chevere
- Department of Emergency Medicine, University of Puerto Rico School of Medicine, 65th Inf. Station, San Juan, PR 00929, USA.
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20
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Salihoglu M, Eroglu M, Yildirim AO, Cakmak A, Hardal U, Kara K. Transoral ultrasonography in the diagnosis and treatment of peritonsillar abscess. Clin Imaging 2012; 37:465-7. [PMID: 23102927 DOI: 10.1016/j.clinimag.2012.09.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 09/25/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the contribution of transoral ultrasonography (TUS) in the diagnosis and treatment of peritonsillar abscess. METHODS We assessed the records of the patients who underwent TUS for suspected peritonsillar abscess. RESULTS We identified a total of 26 patients with a prediagnosis of peritonsillar abscess. Following TUS examination, while the diagnosis was confirmed for 23 of the 26 patients (88.46%), the remaining 3 (11.53%) were diagnosed as having peritonsillar cellulitis. CONCLUSION TUS allows the differentiation of peritonsillar abscess from cellulitis, hence to avoid an unnecessary invasive procedure in the case of a peritonsillar cellulitis.
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Affiliation(s)
- Murat Salihoglu
- Gulhane Military Medical Academy, Haydarpasa Teaching Hospital, Department of Ear, Nose, Throat, Istanbul, Turkey
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Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1509-1512. [PMID: 23011612 DOI: 10.7863/jum.2012.31.10.1509] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Srikar Adhikari
- Department of Emergency Medicine, Northside Hospital Forsyth, 1200 Northside Forsyth Dr, Cumming, GA 30040-1147, USA
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22
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Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med 2012; 19:626-31. [PMID: 22687177 DOI: 10.1111/j.1553-2712.2012.01380.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm. METHODS This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered. RESULTS There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04). CONCLUSIONS An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.
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Affiliation(s)
- Thomas G Costantino
- From the Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA
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Bilateral Peritonsillar Abscesses: A Case Presentation and Review of the Current Literature with regard to the Controversies in Diagnosis and Treatment. Case Rep Med 2011; 2011:981924. [PMID: 21629820 PMCID: PMC3099234 DOI: 10.1155/2011/981924] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 03/07/2011] [Indexed: 11/17/2022] Open
Abstract
Although unilateral peritonsillar abscess is a common complication of acute bacterial tonsillitis, bilateral peritonsillar abscesses are quite rare. The incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%, while the overall incidence of bilateral peritonsillar abscess is reported to reach 4.9%. Diagnosis can be based on clinical criteria or imaging techniques. As far as the treatment is concerned, it is generally accepted that the basic strategy consists of systemic antibiotics and drainage of the pus. We report the case of a 19-year-old girl, treated in the emergency room with a bilateral diagnostic needle aspiration followed by bilateral incision and drainage along with intravenous clindamycin plus anti-inflammatory agents and hydration. Following treatment, the patient progressively experienced a marked alleviation of her odynophagia. She was discharged 48 hours later on a 10-day course of clindamycin.
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Abstract
Ultrasound is gaining momentum for use in the pediatric emergency department. It is important to understand the fundamentals of ultrasound equipment as it relates to pediatric emergency medicine.
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McNeil CR, McManus J, Mehta S. The accuracy of portable ultrasonography to diagnose fractures in an austere environment. PREHOSP EMERG CARE 2009; 13:50-2. [PMID: 19145524 DOI: 10.1080/10903120802474513] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Previous literature has shown the ability of ultrasonography technology to accurately assess orthopedic pathology. Over the past two decades, the use of ultrasound in the prehospital setting has become an important tool for triage, diagnosis, and treatment, especially in austere and remote environments that lack appropriate radiography capability and logistical support. The purpose of our study was to assess the accuracy of ultrasound in the austere, combat environment for diagnosis of orthopedic fracture. METHODS We conducted a longitudinal, prospective, observational study on patients presenting with suspected closed fractures using a digital handheld ultrasound device. All patients presenting with suspected fracture underwent an ultrasound examination by a board-certified emergency medicine physician credentialed in emergency ultrasonography. Patients were then categorized into ultrasound-positive and ultrasound-negative groups. RESULTS A total of 44 subjects underwent ultrasound examination for suspected fractures. There were initially 12 (27%) positive and 32 (73%) negative scans. Of the initial 12 positive scans, ten had a true fracture verified by plain radiography. Ultrasonography yielded an overall sensitivity of 100% and a specificity of 94%. Only four patients with an initial negative ultrasound scan continued to have clinical symptoms for more than three days and were found to have no evidence of fracture by radiograph. CONCLUSIONS Our data show that use of ultrasound by an experienced clinician in the austere environment can be performed accurately and can possibly prevent unnecessary evacuations for suspected fractures requiring radiographic verification. The purpose of our study was to assess the accuracy of ultrasound examination in the austere, combat environment for diagnosis of orthopedic fracture.
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Affiliation(s)
- Christopher R McNeil
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas 78234-6315, USA.
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Ramirez-Schrempp D, Dorfman DH, Baker WE, Liteplo AS. Ultrasound soft-tissue applications in the pediatric emergency department: to drain or not to drain? Pediatr Emerg Care 2009; 25:44-8. [PMID: 19148015 DOI: 10.1097/pec.0b013e318191d963] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Soft tissue infections frequently prompt visits to the pediatric emergency department. The incidence of these infections has increased markedly in recent years. The emergence of community-acquired methicillin-resistant Staphylococcus aureus is associated with an increasing morbidity, mortality, and frequency of abscess formation. Bedside ultrasound may have a significant impact in the management of patients that present to the pediatric emergency department with soft tissue infections, including cellulitis, cutaneous abscess, peritonsillar abscess, and necrotizing fasciitis. Ultrasound is an efficient, noninvasive diagnostic tool which can augment the physician's clinical examination. Ultrasound has been shown to be superior to clinical judgment alone in determining the presence or the absence of occult abscess formation, ensuring appropriate management and limiting unnecessary invasive procedures.
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Affiliation(s)
- Daniela Ramirez-Schrempp
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA.
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Abstract
PURPOSE OF REVIEW Emergency bedside ultrasound has been used by emergency and critical care physicians for over two decades. Its use has grown rapidly in emergency medicine and the range of diagnostic and procedural applications has continued to expand; only recently, however, has this tool been embraced by pediatric emergency and critical care physicians. As this technology develops and becomes more available pediatricians should understand its uses and limitations. RECENT FINDINGS Use of emergency bedside ultrasound for victims of trauma and for procedural applications such as central venous access are well established in adults. Recent published studies suggest that utilizing bedside ultrasound for these purposes may be beneficial in pediatric emergency medicine. Other reports portend future pediatric applications such as assessment of volume status and dehydration, fracture identification and reduction, and aiding in the performance of lumbar punctures. SUMMARY In a review of the literature, it is clear that emergency bedside ultrasound has a role in pediatric emergency and critical care medicine. Much more research is needed, however, to determine which sonographic assessments are of the greatest value. Collaborative efforts will likely be needed to establish definitive applications.
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Abstract
Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.
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Affiliation(s)
- Jason A Levy
- Division of Emergency Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: The evolution of a new imaging paradigm. Crit Care Med 2007; 35:S126-30. [PMID: 17446770 DOI: 10.1097/01.ccm.0000260623.38982.83] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The tradition of clinical ultrasound in the hands of physicians who provide critical care to the most acutely ill patients stretches back into the 1980s and is rich with experiences from surgical, emergency medicine, and other practices. Now, as critical care ultrasound explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field. The development and battles for the right to use ultrasound at the patient's bedside for >20 yrs is described in relation to its emergency medicine and surgical origins. Approaches to education, scanning, documentation, and organization at the national and regional levels are described.
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Affiliation(s)
- John L Kendall
- Emergency Ultrasound, Denver Health Medical Center, Denver, CO, USA.
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Fasano CJ, Chudnofsky C, Vanderbeek P. Bilateral peritonsillar abscesses: Not your usual sore throat. J Emerg Med 2005; 29:45-7. [PMID: 15961007 DOI: 10.1016/j.jemermed.2005.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2002] [Revised: 10/29/2004] [Accepted: 01/19/2005] [Indexed: 11/22/2022]
Abstract
We describe a rare case of a previously healthy 30-year-old man who presented to the Emergency Department (ED) with bilateral peritonsillar abscesses. The clinical presentation of fever, trismus and odynophagia was consistent with pertonsillar abscess (PTA), but the presence of symmetric tonsillar swelling and midline uvula confounded the diagnosis. The true incidence of bilateral peritonsillar abscesses is unknown, but the incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%. The diagnosis of bilateral peritonsillar abscesses should be considered when the clinical presentation suggests the diagnosis of PTA, but the physical examination reveals bilateral swollen tonsils with a midline uvula.
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Affiliation(s)
- Charles J Fasano
- Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania 19141, USA
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Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg 2005; 13:157-60. [PMID: 15908813 DOI: 10.1097/01.moo.0000162259.42115.38] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Peritonsillar abscess is a common problem, but some aspects of diagnosis and management remain controversial. We review the recent literature on peritonsillar abscess. RECENT FINDINGS Intraoral ultrasound can be a helpful diagnostic tool for peritonsillar abscess. For management, needle aspiration, incision and drainage, and quinsy tonsillectomy all yield successful results. Recent reviews have still not established that one treatment is consistently preferred. A randomized, placebo-controlled trail found that the use of intravenous steroids seems to reduce many symptoms, when used along with abscess drainage. SUMMARY The use of steroids may be beneficial in the treatment of peritonsillar abscess, and different techniques for abscess drainage are still used around the world, with consistently good results.
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Affiliation(s)
- Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med 2005; 22:589-93. [PMID: 15666267 DOI: 10.1016/j.ajem.2004.09.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Researchers have described the use of bedside emergency ultrasound as an effective way to evaluate for and accurately drain potential abscesses. Similarly, descriptions exist of long bone fracture evaluation in the wrist and hands. Tendon injury can also be detected with ultrasound and exploration can be obviated or at least focused. Sonographic examination of painful extremity pathology such as abscesses or lacerations involving the hand or foot can be challenging. Patients may be uncooperative if they experience significant pain when the transducer is placed on the area of interest. While ample amounts of ultrasound gel can decrease the need for firm transducer contact with the skin it is still difficult to obtain a good evaluation without causing any discomfort. The solution may lie in an old technique that has been recently brought back to life for use in hand evaluation in which the patient's extremity is placed in a water bath. The water bath replaces the need for ultrasound gel or contact between the ultrasound transducer and the patient's skin, thus eliminating discomfort. We describe 7 cases in which, despite aggressive attempts at pain control, adequate evaluation of extremity pathology was not possible without the use of the water bath technique. Patients reported no discomfort and superior quality images were obtained due to the water bath properties. Emergency sonologists should keep this technique in mind when contact between skin and the ultrasound transducer is likely to cause a patient significant discomfort.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, Atlanta, GA 30912-4007, USA.
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Lyon M, Blaivas M. Intraoral Ultrasound in the Diagnosis and Treatment of Suspected Peritonsillar Abscess in the Emergency Department. Acad Emerg Med 2005. [DOI: 10.1111/j.1553-2712.2005.tb01485.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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